PROLINNOVA Working Paper 18

Innovation in agriculture and NRM in communities confronting HIV/AIDS:a review of international experience1

Michael Loevinsohn2

Applied Ecology Associates, Wageningen, Netherlands

March 2008, revised June 2008

Background

This document aims to review international experience on the role of agriculture and natural resource management (NRM) in preventing and alleviating HIV/AIDS. In particular it draws attention to the importance of local innovation in these efforts and to the experience gained in identifying and boosting local innovation processes. Examples of local innovations of both a social and technical nature are described, as far as possible together with an assessment of the conditions that have favoured or hindered innovation. The purpose is to provide guidance to the country teams in their search for relevant local innovations and in planning for the workshops that they will be organising with partners in both the agriculture/NRM and AIDS/health communities.

We first outline some of the key features of HIV/AIDS epidemics and of their relationship with rural livelihoods dependent on agriculture and NRM. We then discuss in turn how the spread of HIV infection can be hastened when rural livelihoods are undermined and how the illness and deaths that follow infection can contribute to undermining rural livelihoods. This sets the stage for discussion of the roles local innovation play in the struggle with HIV/AIDS and for considering some of the local innovations that have come to light. We also ask why local innovation is not better recognised and appreciated, describe some of the constraints it faces and provide some ideas on ways this initiative can improve the situation.

HIV/AIDS is predominantly a sexually-transmitted disease that is also passed from mother to child during pregnancy, delivery or breastfeeding. In most countries, the first cases of AIDS were observed in cities in the early to mid 1980’s and the proportion of people infected with HIV remains higher in urban than in rural areas. However, infection in the rural areas has tended to increase faster and in some places, including parts of Ghana, Mozambique and Malawi, now exceeds that in towns and cities. Similarly, in the early years infection rates were higher in men than in women. In every region of the world, the difference has reduced over time and in sub-Saharan Africa currently, where the greatest number of infections is found, more than 60% are among women. Young women under 20 years old bear an even more unequal share of infection, often several times that of men their age.

1 A background paper for the country teams involved in the HIV/AIDS and Participatory Innovation Development (HAPID) subproject of the PROLINNOVA (Promoting Local Innovation) programme.2 Member of PROLINNOVA international HAPID team

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Box 1: Key terms used in this review

Susceptibility

Vulnerability

Resistance

Resilience

The likelihood of a person becoming infected by the human immunodeficiency virus (HIV)

The likelihood of a person suffering significant impact as a consequence of HIV infection and AIDS-linked illness or death

The ability of a person to escape or avoid HIV infection

The ability of a person to avoid the worst impacts of HIV and AIDS or to recover to a level accepted as normal

These are general features of HIV/AIDS epidemics but what is striking is the variability of these epidemics. Rates of infection vary greatly between countries and between regions of the same country and these differences appear to be stable. For example, some 3% of pregnant woman are found to be HIV+ in Ghana compared to 30% in South Africa. Within South Africa, 16% of pregnant women are HIV+ in the Western Cape compared to some 39% in KwaZulu Natal (WHO 2006, Department of Health 2006). It is increasingly clear that a wide range of cultural, social, natural, economic and political factors influence people’s risk of being exposed and then of becoming infected with the HIV virus. The risks one faces of progressing from infection to full-blown AIDS and then of dying, and the consequences of illness and death for the household, community, region and country are affected by these same factors and in turn affect them. This bi-directional relationship between HIV/AIDS and the conditions of life is important to bear in mind when considering the role that innovation relating to agriculture or NRM can play in the struggle with the disease. These factors operate at different levels, i.e. some affect an individual’s risks in a fairly direct fashion while others exert their influence indirectly and on many people at the same time.

A conceptual map (Figure 1, Loevinsohn & Gillespie 2003) may be of help in visualising these relationships and situating the role of local innovation. At the centre lies infection by HIV. The top left section illustrates the causes of infection, beginning, in the innermost circles, with the most direct and immediate (e.g. nutrition) and progressing leftwards to the most indirect (e.g. climate and policies). The top right-hand section illustrates the consequences of infection beginning again with those that are most immediate, experienced by infected persons themselves, and progressing through the effects experienced by households, communities and countries. The bottom panel of the map portrays some of the principal opportunities for intervention and the level at which they can be implemented: those advancing prevention on the left, those addressing care, treatment and impact mitigation on the right. The following sections describe these linkages and opportunities in more detail and some of the ways in which they vary in different situations.

Food, livelihood and HIV infection risks

People vary in their likelihood of becoming infected with HIV, that’s to say their susceptibility. Infection with another sexually transmitted disease such as syphilis, herpes and gonorrhoea facilitates the entry of HIV and is among the most important of the immediate causes of infection. Malnutrition, particularly vitamin A deficiency, favours a number of sexually transmitted infections and together chronic malnutrition and parasite burden weaken a person’s immune function, making HIV infection more likely (Auvert et al 2001, Stillwaggon 2002). Transmission of the HIV infection from mother to child is also affected by her nutrition and immune status. There are often important seasonal patterns to maternal nutrition in rural areas, linked with the hungry period before harvest and to the times of heavy work in the field. These seasonal effects are often most pronounced among the landless or those otherwise marginalised (Kinabo 1993, Bang et al 2005). Rural people

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are often well aware of the close links between food, nutrition and health even if the details of the interactions are not always apparent to them.

HIV being a sexually transmitted infection, sexual behaviour – sex with whom and under what conditions – is central. There are many influences on these decisions. Culture is one, influencing, for example, the age at which one initiates sex and with whom, the age at which one expects to marry and – later in life – whether and with whom widows remarry. Knowledge of HIV and AIDS is also crucial: how one becomes infected, the ways in which one can avoid infection, how HIV relates to AIDS and the consequences of the disease. The combination of intimate knowledge of the disease (many people knowing someone who has it or has died from it) and frank discussion among family and friends – what has been called the “social vaccine” – appears to have been an important factor in limiting HIV’s spread, particularly in Uganda (Low-Beer & Stoneburner 2004). We return to this further below.

Figure 1: AIDS map: causes, consequences and responses (Loevinsohn & Gillespie 2003)

However, one’s ability to act on what one knows is often constrained. In particular, poverty – notably hunger and lack of opportunity – and inequalities – especially those between men and women, among social groups and between rural and urban areas – can force people into situations where they are at heightened risk of becoming infected with HIV. Common situations of risk include:

Transactional (“survival”) sex, where especially women are obliged to sell sex for food or money in order to keep themselves and their families alive. There are times when casual labour contracts have become abusive and women have been forced to have sex in order to have work (Bryceson 2006). In these conditions, it is difficult for the woman to insist on safe

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sex. Note that the relationship turns on inequality: a woman who is forced to sell sex; a man, better off, who is prepared to buy. Research in Botswana and Swaziland has found that women who had recently been hungry were more likely to have sold sex and to have agreed not to use condoms than those who had had enough to eat. The link was much less pronounced for men (Weiser et al 2007).

Migration, where people are obliged to move away from home in search of work or food, either to towns or cities or to more favoured rural areas. There may be particular risks for those who move in distress: alone, often with few contacts or skills, they are at heightened risk of becoming involved in risky sexual behaviour. Other people may be impelled to move more by lack of opportunity where they live than by distress per se, for example many seasonal workers at plantations, rural industries or mines. Again, however, conditions there may put them at increased risk of infection, e.g. separation from their families, staying in same-sex dormitories and payment that is sometimes late and often received all at once (Ngwira et al 2002). In every developing region, migrants are almost invariably case found to have more extramarital sexual relations and to be more often HIV+ then non-migrants (Decosas et al 1995, Mehendale et al 1996).

Early marriage, where girls or young women are pushed, in many cases by their families, into marriage with older men. Poverty often lies behind these pressures. The man, being older, is more likely to be infected than the girl/woman or than boys/men of her age. Girls may still be physiologically immature and so more susceptible to infection. Often living far from home, they are isolated and have little support (Bruce & Clark 2004).

Sexual violence, more often than not in the home and at the hands of a partner. Poorer women – young, poor women in particular – are generally at increased risk of suffering violence. They may also be more susceptible to HIV infection since partners who engage in such violence are more likely to be migrants or often travel, to drink alcohol to excess and to have sexually transmitted infections (Campbell 2002, Dunkle et al 2004).

Several of these situations of risk have a seasonal character in rural areas. Survival sex may be more common in the hungry season and when there is no work in the field, based on accounts from South India and Malawi (pers. obs.) and migration in many areas is highly seasonal.

Policies of various kinds can be seen to influence these situations of risk. In many countries, long periods of underinvestment in rural areas have left villages isolated and poorly served by transport, irrigation, schools and markets. Deteriorating terms of trade for farmers have led to falling real incomes and limited their ability to invest in their enterprises. In many countries, policies, consciously or not, have pushed farmers into reducing on-farm biodiversity and/or limited their access to wild resources important for food security. These have left them increasingly vulnerable to climatic variability and to volatile prices for their produce or their consumption staples.

All these factors can be seen to have played a role in the Malawi food crisis of 2001–03 (Box 2).

Box 2: Hunger and HIV in Malawi

There is a consensus among observers that the food crisis in the country in 2001–03 was not just a result of the early flooding followed by poorly distributed rains through the 2001 and 2002 crop seasons. Over several decades, government policy promoting maize at the expense of more drought-tolerant crops and underinvestment generally in the rural areas had left agriculture vulnerable to climatic variation. These policies together with actions in the immediate term, notably the ill-considered sale of the Strategic Grain Reserve and key decisions regulating grain sales, provoked a surge in the price of maize that put it out of the reach of many.

Evidence from several sources describes hunger pushing people further into already familiar situations of risk. But it did so unequally: women were more affected than men, some rural areas were worse hit than others and hunger was more severe in the villages than in towns and cities. There are widespread accounts of rural women being obliged to turn to survival sex. Young women referred to it, ruefully, as

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“screwing to die”. Opportunities to do casual labour (ganyu) became scarce and employers extorted sex. There was also widespread movement in search of food or work, to cities, towns and plantations.

A recent study has found a clear imprint of these effects on HIV infection rates in women across the country (Loevinsohn 2007). Over the course of the food crisis, HIV rates increased in rural areas, increasing the most where hunger was the most widespread. In contrast, HIV rates declined in towns and cities, declining the most where hunger in the surrounding rural areas was most widespread. This latter is at first sight a surprising result, but it can be explained by the movement of women, especially young rural women, to the towns and cities. HIV rates in the villages were less than in the towns and cities so, when young rural women moved, they brought down urban infection rates and brought them down most sharply where they moved in largest numbers. This is by no means a desirable result, for they moved into an environment of substantially higher infection rates and moved there in distress.

What is striking is that factors acting indirectly on susceptibility to HIV – notably ill-considered decisions that affected the price and availability of maize – exerted such a large and rapid impact on HIV infection rates. More positively, the experience also suggests that actions which reduce rather than increase food insecurity and vulnerability to climatic variability can help people avoid situations of risk and thus make an important contribution to HIV prevention. We return to this possibility below.

AIDS, hunger and livelihood

Turning to the top right side of Figure 1, the most immediate consequences following from infection are progression through the various stages of the disease, through opportunistic diseases to full-blown AIDS and death. Nutrition plays a crucial role. HIV infection itself provokes an increased energy demand in adults – and even more in children – that, if not met, contributes to a suppression of immune function, hastening progression through the disease stages. Protein and micronutrient needs are not necessarily increased by HIV infection, but immune function can be further compromised if they are not met (World Bank 2007). People who are malnourished when they become infected or who become malnourished thereafter are at risk of progressing more rapidly through AIDS: they can be said to be more vulnerable to rapid progression.

People who are malnourished are also vulnerable to poor outcomes if and when they begin antiretroviral therapy (ART). Particular drug regimes have specific and sometimes complicated requirements in terms of the type of foods that can be eaten and the timing of meals. Counselling and food supplementation are recommended elements of ART programs and of particular importance in areas of food insecurity (World Bank 2007).

For the household, the illness and subsequent death of an adult member has a suite of consequences. The labour that the infected person contributed to the household’s enterprises is first much reduced and then lost entirely. Of often equal importance is the diversion of especially women’s time to caring for the ill. Households are also confronted by often formidable expenses for treatment, transport to hospital, care while there and eventually for the funeral and attendant rites. Further demands are placed on households when members or other relatives who had been living in town or city return ill: beyond the additional time and expense, remittances they previously sent are now lost.

Rural households respond in a variety of ways to these developments. Some responses are widespread and can be called typical. Savings are mobilised and assets sold to meet the expenses. Households often reduce the area they cultivate and farm it less intensively, leading to a fall in production. They also tend to concentrate on crop or livestock species that require less attention and fewer inputs, producing less for the market and more for their own subsistence. Households may also increase their reliance on day labour to meet immediate needs. Children may be kept home from school both to reduce expenses and to provide additional labour. Families are often forced to reduce the diversity and quality of the foods they consume and the number of

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meals they take. Access to wild plant or animal foods can be an important counterweight to this trend (Barany et al 2005, Hunter et al 2007).

These and similar responses are often referred to as “coping” but the term is misleading. It implies that people are getting by or doing well enough (Rugalema 2000). In fact, for many the consequences of AIDS are devastating, and recovery to a decent level must seem at best a distant prospect. Families are all too aware that some of their responses push that prospect back further, for example when they take their children out of school or sell land. Similarly, “tuberisation” – expanding the area planted to root crops like cassava and sweet potato at the expense of grains and legumes – can help people meet their energy requirements and reduce peak labour demand. However, relied on to excess for subsistence, they can undermine nutrition.

Women are often more vulnerable than men to suffering the worst consequences following from AIDS-linked illness and death. Widows’ continued access to the land they had cultivated may be fragile and they may be forced off by the husband’s relatives or obliged to marry one of his brothers. Inheritance practices vary according to culture, and women’s rights are generally more secure in matrilineal than patrilineal systems. Under the pressure of AIDS, inheritance laws in many countries are being changed to better protect women’s rights, but enforcement typically lags well behind (Ngwira 2002, The Chronicle 2005).

The impact of AIDS is generally greater among individuals and households confronting other threats as well. Individuals infected with tuberculosis or malaria respond poorly to treatment and suffer worse outcomes when co-infected with HIV (Corbett et al 2003, WHO 2004). Households initially poor are more affected by an AIDS-linked illness or death than wealthier households (Yamano & Jayne 2004, Nombo 2007, Chapato & Jayne 2008). As described earlier, the food crisis in Malawi in 2001–03 was provoked by the confluence of long-term declines in soil fertility and agrobiodiversity, flooding and poorly distributed rain, and questionable decisions in the management of grain stocks and trade, leading to a prolonged rise in the price of maize. As the crisis deepened, rural households that were harbouring chronically ill adults (a proxy for AIDS) cut back on their food intake more than other households and were more likely to have one of their adult members migrate in search of food or work (Vulnerability Assessment Committee 2003). This last effect is particularly disquieting because distress migration is a situation of HIV risk. Similarly, orphans who face diminished livelihood opportunities are also often at greater risk of engaging in survival sex than their peers. When those most vulnerable to AIDS’ worst effects are also highly susceptible to HIV infection, the stage is set for a downward spiral stretching over generations.

The impacts of AIDS spread beyond the household. Grandparents (grandmothers in particular), siblings and sometimes friends take in and care for orphans. Village groups or communities as a whole may contribute to their care and education; they have in many cases also provided support to those too sick to work and contributed to funeral expenses. Responses at this level have been crucial in many areas and we consider them in greater detail below. But the limits to group-level and community-level responses are also evident.

Widows and orphans often find themselves denied access to common property resources that are important as food or for their market value. This has been the case with wild fruit (baobab and tamarind) in parts of Malawi that are now sold to be processed into juice (Page 2003). In these cases, evidence is often not hard to find of the stigma attaching to AIDS and those who have been close to it, still strong in many areas. Exclusion may be enforced by simple power or, in the case of collectively managed resources, by rules that demand a contribution of labour. Rigid divisions of labour may prevent widows and younger orphans from taking over the work of their husbands and fathers, as has been reported in fishing communities on Lake Victoria in Uganda. The widow may be obliged to sell the boat or to cohabit with a younger man who will operate it, options that have their own hazards (Tanzarn & Bishop-Sambrook 2003).

Vital to the capacity to innovate is access to information and new materials (e.g. seeds or tools). There is a danger that those affected by AIDS may be excluded from the networks, particularly the

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informal ones, through which these circulate. Stigma again may play a role but also the fact that those diminished by AIDS will have little to offer to these networks that function through reciprocity. This is a risk faced by the rural poor in general in agricultural communities (Sperling & Loevinsohn 1993).

The functioning of community-level institutions may be imperilled by the rising prevalence of illness and death among their members and leaders. This may affect the community-level safety nets of orphan care and support to the ill, as well as those charged with the management of natural resources. Support institutions providing credit, transport, information and education can also be weakened, negatively affecting the community.

Innovation and resistance to HIV

When people have intimate experience of illness and death linked to AIDS and are able to openly and frankly discuss their causes and the situations of risk they themselves confront, they contribute to what we referred to earlier as a social vaccine. However, it is a far from perfect vaccine. Being aware of HIV and AIDS and recognising one’s personal risks doesn’t mean one is able to alter or avoid them. Responding effectively requires breaking out of the hazardous situation. It demands innovation (Box 3).

Box 3: Vegetables and survival

Tifaranji (“Why should we die”) is a large group in one village in Zomba District, Malawi. During a meeting near the height of the food crisis in January 2003, a young woman speaks with eyes averted of other women in the village being sent out at 4 PM to bring back a bowl of maize meal – and no one asks them how they got it. Another nods and says girls have been sent out in the same way to get kerosene for the lamp.

The meeting has been called to discuss priority actions to counter the hunger and eventually one of the young women describes a plan a few of them have discussed. They want to grow vegetables on riverside dimba land in the winter season and sell them to the nearby teacher’s college. They have their eyes on a particular patch of unused land. Will the village allow them to use it? There is no immediate reaction from the chief and other prominent men. Other issues are discussed: maize seed, fertiliser, orphans. After a time, another of the young women speaks up. They could achieve much more, she says, if they had the use of a treadle pump. These are being promoted and subsidised by a programme of the Ministry of Agriculture and Irrigation but one of the criteria is that they can only be given to heads of households with land. Can the village intercede on their behalf?

There is more discussion. The meeting ends without any decision.

What the young women were attempting was an innovation: doing something different, or differently. Whether they succeeded in this case depended not just on their own efforts but on responses at other levels as well, the village and the Ministry. Innovation at these levels, changing rules and procedures so that young, landless adults can gain access to land and subsidised treadle pumps was essential.

If the women succeeded and made a go of the venture, they would have increased their resistance to HIV infection, their ability to escape or avoid infection. Resistance to infection is often considered a matter of the immune system and cell physiology but the term is fully applicable in cases such as the above. The immunity-based as well as the livelihood-based actions both involve processes of awareness, recognition and targeted response. And resistance is more than merely the opposite of susceptibility: resistance involves an active response where susceptibility is passive.

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Actions of the sort the young women in Zomba were planning, if widely repeated, could make a real contribution to HIV prevention in rural areas. The women were certainly motivated: the hazards were clear and immediate to them. However, we know of few other such examples where the impetus for innovation has come from those at risk. We consider further below why this might be, why more examples of locally-led resistance to HIV/AIDS involving innovation in agriculture or NRM have not come to light. However, we can suggest some places and situations where such innovation may be present but yet to be recognised or reported. If one is looking, these may be the most likely places to find such innovation:

• Communities in a number of cases have altered cultural practices in order to reduce HIV infection risks, including the way the young are socialised around sexuality and specific initiation rites. The discussion that made these changes possible may also have spurred or supported innovations with similar intent in agriculture or NRM.

• Numerous agencies, notably several NGOs, employ adult education approaches to promote awareness and recognition of personal infection risks that especially young adults face. Action Aid’s Stepping Stones and Reflect are examples (Nakiboneka 2006). The final step of these processes is often a list of priority actions the participants will undertake. Often they relate to livelihood. Often no further support is provided by the agency, and no one reports on what the participants go on to do on their own.

• Some HIV/AIDS education programs have taken a further step. In rural Limpopo Province, South Africa, one such effort aimed in particular at enhancing women’s ability to resist gender-based violence and its HIV risks by integrating a micro-credit initiative with the training. Evaluation found that women in the program indeed suffered less violence, though there was no evidence of a reduction in new HIV cases among the women or in the wider community (Pronyk et al 2005, 2006). No mention is made of the innovations women actually made in their enterprises, agriculturally-based or not, on the strength of these additional resources.

• Some rural development programs have tried to assess how HIV/AIDS is affecting their efforts and the communities they work with and how they should adapt their efforts to the new realities. Oxfam’s Shire Highlands Sustainable Livelihood Program in southern Malawi (Oxfam 2004) and CARE’s Viable Initiatives for the Development of Agriculture (VIDA) in Nampula Province, Mozambique (CARE 2004) have both done such an assessment, making use of what can be called an “HIV/AIDS lens”. One outcome has been a re-orientation of efforts to reach out to new groups, notably young men and women with few livelihood options and at risk of falling into survival sex and similar situations of infection risk. Again, the documents make no mention of local innovation in agriculture or NRM that may have been recognised or stimulated by these changes. We return below to the HIV/AIDS lens.

• There are also programs which in their design specifically address agriculture and NRM issues relating to HIV prevention and AIDS mitigation. These include the Kitovu Mobile Farmer School in Uganda (White & Morton 2005), the Farmer Life School in SE Asia (Vuthang 2003, Ou 2004) and the Junior Farmer Field and Life School in Mozambique and a number of other African countries (FAO 2007). Their curricula usually include “life skills”, an appreciation of the disease environment – crop as well as human – and an emphasis on experimentation. At least some of their graduates can be expected to apply these skills and to innovate in their own fields.

• It was suggested earlier that efforts that have helped communities confronting HIV/AIDS secure food and livelihood may be making an unsuspected contribution to prevention. In Malawi, as in other countries, community-managed grain banks have emerged that aim to moderate the large seasonal swings in maize price (farmers sell low and buy high). Helping people avoid the familiar situations of infection risk may not have been the explicit intent when these banks were established, but they may well have had that effect. Perhaps some are aware of that benefit. Perhaps they seek to enhance and extend it.

• Numerous large-scale programs seek to improve the management of natural resources and enhance rural livelihoods. Many are conceived and designed far from the people they are intended to serve: participation is generally an add-on. There are some, however, which consciously seek to benefit from local innovation and to ensure that actions are adapted to

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local conditions and opportunities. This includes several experienced NGOs working in rainfed areas in South India on watershed development and related livelihood activities (Fernandez 1994). Their efforts have resulted in broad improvements in welfare, one consequence of which has been a substantial reduction in at least one particular situation of HIV risk – seasonal migration. They may thereby be preventing significant numbers of HIV infections, as a recent study found that brought an epidemiological model to bear on the case (Loevinsohn 2006). Again, HIV prevention wasn’t the intent of these efforts, but the NGOs say they would welcome this “dividend” if confirmed – as doubtless would the people involved. There are certainly ways in which the benefit could be enhanced, especially by joining it with HIV/AIDS education of the kinds mentioned above.

Innovation and resilience to AIDS

A number of examples are known of local innovations in agriculture and NRM that have enabled individuals living with HIV/AIDS and households enduring the consequences of AIDS-linked illness and death to improve their situation. These are responses that go beyond the typical ones that are captured by “coping”: they hold out a realistic prospect of people avoiding the worst consequences of AIDS or recovering faster to a level they would see as normal. This is what is meant by resilience. Like resistance, resilience refers to active and conscious responses. Resilience is more widely discussed than resistance but there is still surprisingly little evidence regarding the specific innovations that make it possible. We come back to this matter below.

Technical options that save labour or spread it more evenly – cassava is often cited – are thought to dominate the choices of households affected by AIDS (Du Guerny 2002). However, other patterns are visible as well in the local innovations supporting resilience that have come to light3:

• Making efficient use of remaining labour and other resources. Ncube (1999) describes the development of a light cotton planter by Zimbabwean farmers that is made of inexpensive material and can be drawn by a donkey. Oxen had previously been used but are difficult to handle by women and youths. Many of these planters have been sold.

• Reforming gender roles. Examples cited here and others described by Mutangadura et al (1999) provide evidence of surviving household members growing crops, raising animals and exploiting natural resources with which they were previously little involved – despite the opposition sometimes encountered that was noted above.

• Focusing effort on parts of land holdings and diversifying. Gabriel Rugalema (pers. comm.) recounts the efforts of a group of orphans in northern Tanzania to grow vegetables for the Mwanza market on a well-watered and fertile plot that one of them had access to. They employed intensive production practices – including the use of hazardous pesticides – that they had little experience with or guidance on.

• Exchanging labour to overcome peak labour demands. Neema (1999) recounts how Ugandan widows exchange labour especially during land preparation.

• Expanding opportunities by adapting new technologies. Josef Decosas (pers. comm.) describes the case of a group of Mozambican widows whose husbands had previously collected honey from the forest, a practice the women felt unable to continue. Instead, they took up apiculture – an introduced technology – but constructed hives from local materials in place of the expensive commercial ones.

• Expanding opportunities by adapting existing technologies. Homegardens are widely practised but have a number of characteristics of particular importance for people living with HIV/AIDS or dealing with its consequences, including spreading labour demand through the year, enhancing security and permitting intensive cultivation of diverse crops with complementary nutritional and medicinal properties. Murphy et al (2007) describe households in Kenya adapting

3 This section draws on Loevinsohn and Gillespie (2003).

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homegardens to different ends, choosing among a range of local and introduced elements and practices (Box 4).

Box 4: Homegardens in western Kenya

Homegardens and intensive horticulture are not new to Kimiluli village, Bungoma District but what is new is the intense and dynamic hybridisation that HIV/AIDS has stimulated. New crops and varieties such as soybean and sweet potato enriched with beta-carotene (a vitamin-A precursor) are being grown alongside common staples and some “old” vegetables, grasses and trees that have been given a new lease on life. Raised beds, intercropping, compost pits and trenches for catching water are among the techniques that are being taken up to sustain year-round, multi-purpose gardens. But they are being adopted selectively and are being modified. For example, some widows are using compost piles rather than pits because they cannot muster the necessary labour.

Diversity among the gardens in the village reflects diverse motivations. Some gardens are cultivated by people living with HIV/AIDS or by family members caring for them who seek in particular to safeguard their health by bolstering micronutrient consumption and diet. Access to medicinal plants useful in treating opportunistic and other infections is also an objective. Others are tended by AIDS survivors – widows and those caring for orphans – not necessarily infected themselves, who seek to improve the household’s food security and reduce expenditures. There are also gardens tended by support groups that serve to provide orphans and widows in the village with food or cash generated by sales. Members donate as well from the production of their own gardens.

A local NGO has apparently played an important catalytic role in these developments. In 2004, it began to work with a handful of farmers, some of whom had lived or travelled in other regions and were already familiar with gardens and organic farming and understood the importance of diet in maintaining health. The training the NGO provided emphasised the links between HIV/AIDS and food and nutrition and introduced several new farming techniques. It also made available seed and cuttings of new crops and varieties, as well as of local plants once common that farmers now wished to bring back into their gardens.

Ideas and some planting material are spreading through informal networks within the village. The assessment (Murphy et al 2007) was carried out only a year after the NGO training but spread appears to be limited by several factors. Households farthest from wells or streams are least likely to have planted these new gardens. Some households are willing but lack access to critical seeds and knowledge. Some appear to be unconnected to the networks due to poverty and illiteracy. There are other households, however, who might benefit from the new gardens but appear unwilling to take up techniques or crops promoted by an HIV/AIDS-oriented NGO, associating them with “that” disease.

Innovation by rural communities has been critical in the struggle with HIV/AIDS and has often emerged long before outside agencies have mobilised and appeared on the scene. Support to households caring for the sick, burying the dead and raising orphans has generally built on existing practices and community institutions – formal and informal (Mutangadura et al 1999, Lwihula 1998). The demands have grown steadily as HIV/AIDS epidemics have intensified and a number of case have been documented where communities have met the challenge by diverting land, labour or other resources to such support.

Hesselbach (cited in Connolly 2003) describes an interesting case in the Southern Province of Zambia involving innovation at both the household and community levels. Pit farming, a form of conservation agriculture, is spreading rapidly there from farmer to farmer. This entails planting crops in pits 120–180 cm in diameter and 60 cm deep filled with topsoil, compost and crop residues. The pits demand a large initial input of labour but much less than conventional approaches in subsequent seasons and they conserve fertility and moisture. To enable HIV/AIDS-affected households to adopt the practice, villages have pooled labour, including that of unemployed youths, for the onerous tasks of digging and filling.

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In central Malawi, Shah et al (2002) observed that many villages had established funeral maize banks. Each household was expected to contribute a certain amount of maize to the bank each year on which they were then entitled to draw in case of a funeral. Households unable to contribute were not eligible for support. Community action there appears to have been less far-reaching than in Zambia both in the range of needs addressed and in terms of equity – reaching out to those unable to contribute themselves. Why one community rises more successfully than another to the challenges posed by HIV/AIDS is clearly a critical question for those seeking to identify and promote local innovation. Some insight can be gained from Nombo (2007, Box 5) who describes the very different response in two neighbouring villages in the Morogoro Region of Tanzania. She believes trust and social cohesion are essential conditions for the development of effective community action.

Box 5: Community support in Tanzania: a tale of two villages

Mkamba is a village of some 12,000 inhabitants spread over six hamlets in Kilombero District. Rainfed maize, rice and sugarcane are the mainstay of people’s livelihoods, supplemented increasingly in recent years by paid labour in other people’s fields and a range of non-farm pursuits including beer brewing, charcoal making, market trading and construction. Some are also employed by a large sugar factory and its plantation. The village is readily accessible by road and rail and has experienced substantial in-migration over a number of years, in large part due to the employment opportunities at the sugar factory. Out-migration by the young is also widespread.

AIDS heavily affects the village and accounts for a large proportion of adult deaths. Households hit by illness and death rely on family and close friends for support but social networks and local institutions, formal or informal, appear to play very little role. Villagers interviewed spoke of the increasing burden that most families now experience that has undermined mutual aid:

“Who is there to give you food and money these days? Everyone has to strive for her or his own family.” And:

“Even if you have friends, it is just ‘on the mouth’. We cannot help each other because our circumstances are the same: if it is business’ bad performance, then it is likely they experience the same. If it was bad weather, then we are all likely to be affected. Now who is to help the other?” (Nombo 2007, pp163–164)

Others spoke of widespread suspicion, sometimes manifested in accusations of witchcraft, which impede people from helping friends or neighbours in need.

The experience in the adjacent village of Kidatu has been very different. Only slightly smaller than Mkamba and with a similar livelihood base, villagers have nonetheless managed to agree on collective measures to support those in need. A village development fund has been established, financed by revenues from a quarry and a sugarcane farm. Some 60 ac in area, this farm is worked by individuals and groups who pay rent to the village fund. This is used to support in various ways those identified as HIV/AIDS-affected or very poor. Orphans of school age are provided with uniforms and school supplies. Fees are waived when they visit the village dispensaries. And households fostering orphans receive financial assistance.

The study devotes only a page to Kidatu and provides little insight as to how the collective response there was arrived at. The author ascribes the markedly different response in the two villages to the greater social cohesion in Kidatu. In- and out-migration is said to have been less in recent years, which has helped to preserve a sense of kinship that is no longer evident in Mkamba. Kidatu’s leaders are also said to have acted responsibly, ensuring funds are used for agreed development and assistance purposes.

Synergies, overlaps and opportunities

To this point, we have seen evidence, though still limited, of local innovation in agriculture and NRM that supports resistance to HIV infection, thereby advancing HIV prevention. The examples presented above provide more evidence of local innovation that supports resilience. Several

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contribute to the care of those living with HIV/AIDS – including self-care – by enhancing nutrition. Understanding one’s nutritional needs, having access to foods that can supply them and seeking prompt treatment of opportunistic infections are key elements of what The AIDS Support Organization (TASO) calls “positive living” (Mukasa Monico 2001) which offers people living with HIV/AIDS a realistic prospect of a longer, disease-free life. We have also seen evidence of local innovation in agriculture and NRM that supports mitigation of the consequences of illness and death for affected households. To our knowledge, innovation that supports treatment with ARTs has yet to emerge but could make an important contribution to the sustainability of treatment programs that now rely on externally-provided nutrition support.

There are synergies between mitigation and prevention that are important to recognise. For example, orphans who are well cared for and enabled to continue their education are less likely to fall into situations of infection risk such as survival sex (Loevinsohn & Gillespie 2003). Innovations that enable them and those who care for them to surmount the immediate challenges can help them escape the downward spiral of infection-impoverishment-infection referred to earlier. The same may be true of innovations supporting widows heading households who often face hazardous choices.

A related point bears emphasising. The same technical options may be of use to people in different situations. A treadle pump, for example, can be employed by a young woman at imminent risk of HIV infection, a widow trying to feed her kids, a grandmother raising her grandchildren (if they do the pumping!) or someone facing similar challenges but not immediately affected by HIV/AIDS. What marks an innovation as one that supports resistance to HIV infection or resilience to AIDS’ effects – advancing prevention, care or mitigation – is the intention and the effort made to adapt the pump (or whatever) to the person’s capabilities and particular situation. In the case of the young women in Malawi discussed above, the key to change was innovation at the level of the village and government agency.

That said, some innovations may be more attractive to people who are especially susceptible to HIV infection and others to people especially vulnerable to AIDS’ worst consequences: clearly, young men and women, usually single, will typically be looking for different kinds of opportunities than will heavily burdened widows and grandmothers. These differences can be turned to mutual advantage. For example, one community-based organisation in Malawi made cassava and sweet potato cuttings available to vulnerable households with land. Orphans and other young adults were also supported to set up a small bakery where they made a range of products from cassava flour (CARE 2006). Other possibilities along these lines – innovations that advance mutual benefits – can be glimpsed and may need only a nudge to emerge. Those young adults have abundant labour but no land. The widow or grandmother may have land that she cannot cultivate, or cultivate fully, for lack of labour. What stops her from renting them the land against a reasonable share of the harvest? Perhaps only that her tenure is insecure. Assuring her secure tenure may actually be the key innovation that makes further ones possible. And as with the young women in Malawi, it requires action by others, in the community or outside.

Recognising and supporting local innovation

We return to the question raised earlier: why is it that we don’t we see more innovation in agriculture and NRM by people and communities confronting HIV/AIDS? Several factors are likely involved that deserve careful consideration by organisations, whether on the agricultural/NRM or health/AIDS side, wishing to support such innovation.

Firstly, there may well be local innovations that have emerged and been taken up, without much fanfare, in NGO or government programs. Efforts to support rural livelihoods such as those mentioned earlier – CARE’s in Mozambique and Angola (CARE 2004), and Oxfam’s in Malawi (Oxfam 2004) – that seek to foster participation and that respect local knowledge may well have come across local innovations and facilitated their spread. That may also be the case in programs

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that build on existing technologies like the homegarden, for example Concern’s nutrition garden project in Zimbabwe (Keatinge & Amoaten 2006) and CARE’s homestead garden project in Lesotho (CARE 2005). It is quite possible that crops, varieties or practices that have been developed or refined locally are being promoted by these efforts. If indeed such “borrowing” has taken place, the fact that there has been as yet no overt recognition may only be an oversight. It is also possible, however, that some programs do not appreciate the potential of these innovations and make no particular effort to seek them out. Perhaps more importantly, the organisations may not appreciate the potential of local innovation processes and the contribution they can make, if intelligently supported, to the local adaptation, local ownership and sustainability of the programs.

Secondly, there may be local innovations out there that have not come to light because few people are looking or have an eye for them. Much of the information on which policymakers, program developers and researchers draw comes from surveys employing fixed questionnaires. The results are usually expressed as a mean or a frequency, for example, so many percent responding in a particular way to an adult’s illness or death. The unusual response is likely to be classed as “other”. Case studies and in-depth interviews too often are selected to illustrate the typical rather than the unusual. And yet it is the different response, the unusual approach that holds out most promise. There are certainly methods that can do a better job in identifying them but they require a less superficial involvement in each place.

The blindness to local innovation is all the more marked with respect to resistance to HIV. Investigations into the links between HIV/AIDS and rural livelihoods have generally been done by people with rural development and agricultural backgrounds concerned about the impacts of AIDS on rural livelihood and society. That weaknesses in rural livelihoods and society might also be contributing to the spread of infection and that innovation can do anything to reverse these risks have proven more difficult to grasp. You’re not likely to recognise what you’re only dimly aware exists.

Thirdly, local innovation may be stifled because of the atmosphere prevailing in the household or community. People may have wanted to innovate in a manner that could help them avoid a situation of HIV infection risk or deal better with the effects of AIDS-linked illness and death but may be thwarted from realising the innovation or talking about it because of what lies behind it. HIV/AIDS remains for many a feared and fatal disease, despite the roll-out of treatment programs. Inequalities, sex and power are wrapped up in its causes and its consequences. All these factors contribute to stigma and exclusion, leading, for example, to certain people being left out of meetings or pushed to the back or dropped from the informal networks through which information and material crucial to innovation circulate. The opposite may also occur. There may be resentment about the priority that is given by some programs to people affected or threatened by HIV/AIDS at the expense of those confronting other hazards to health and livelihood. There are certainly other causes of chronic illness in adults than HIV/AIDS and they are likely to be the more numerous where the prevalence of HIV infection remains relatively low.

Box 6: Equity – in hard times

Tifaranji (“Why should we die”) group, Zomba District, Malawi. A meeting near the height of the food crisis, January 2003, the same as described in Box 3.

The chair, one of the village leaders, recounts some of the efforts that are underway. Village land near the river has been donated for vegetable production. People – men and women – are working the plots individually or cooperatively and giving one day per week for AIDS mitigation. Vegetables are given to the sick to improve their nutrition. Some are sold to provide funds to support those caring for orphans. Mentors are working side-by-side with orphans so that they can learn agricultural practices and become self-supporting.

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A young woman turns away. It’s not enough to talk, she says. On her way home yesterday she was offered Kw50 (USD 0.60) for sex. Another speaks up: I was offered Kw20.

Box 6 provides a snapshot of a village struggling to respond in an extreme situation. It appears at this point to be responding better, indeed creatively, to some people, those living with HIV/AIDS and its consequences, than others, notably young women with few other options than survival sex and at great risk of HIV infection. It was these women who were pushing for support of their ideas on using dimba land to grow vegetables in the winter season (Box 3). Was there a connection between the fact that it was men from the village who were offering them money for sex and, to that point, the lack of support from the village for their plan?

How does one, coming from the outside, support the innovation processes visible in such a case? There are no easy answers and there is not the space here to give the question the consideration it demands. We suggest that a workable response, one that advances the rights of people at risk, can only be developed by people and organisations that are committed to making a difference locally. The elements of that response may well be found in the diverse experiences of people and organisations that come to the problem from different sides, notably agriculture/NRM and health/AIDS.

It may be useful, however, to lay out an approach that could be employed in the planning and capacity-building workshops that the country teams will be organising to help people from these different backgrounds develop a common understanding of the relevance of agriculture and NRM to HIV/AIDS, and the place of local innovation. The “HIV/AIDS lens” is intended to aid decision makers at any level to re-view situations (e.g. a food crisis, a rise or fall in the price of a major agricultural commodity) or actions (e.g. a new extension policy, a village grain bank program) in the light of HIV/AIDS, helping them to reflect on how the situation may be affecting, positively or negatively, HIV/AIDS-related risks and how the action, actual or planned, might contribute to these effects. Different versions of the lens have been described (e.g. Keatinge & Amoaten 2006, CARE 2004) but all are fundamentally similar. Box 7 suggests how the lens might be adapted to the workshop setting, drawing on the approach of Loevinsohn and Gillespie (2003).

Box 7: Moving towards a common understanding

We assume that the workshops will bring together representatives of organisations that have a strong field orientation and are involved in community-based HIV/AIDS control or support to livelihoods based on agriculture or NRM. Somewhere near the beginning of the workshop one might make time for the HIV/AIDS lens exercise.

To begin, it will be helpful to review the basic “facts” of HIV/AIDS and of agriculture and natural resources in the country or region. Introduce the concepts of susceptibility and vulnerability, resistance and resilience and how these relate to the goals of HIV/AIDS control: prevention, care, treatment and impact mitigation. The facilitator then solicits from the participants situations and actions that can be used as working examples. Say that from among the suggestions, participants agree to use the high levels of out-migration in recent years from several rural regions of the country and the responses of individuals, households, communities, agencies and government.

The facilitator then asks the group: how may the out-migration be affecting susceptibility to HIV? Participants are encouraged to draw on what they have seen or heard or what they believe may be occurring, based on their experience. The facilitator ensures that the participants’ complementary experience emerges, for example that of an AIDS-oriented NGO using popular education to teach migrants about the situations they may find themselves in when they reach the city, an agriculturally-oriented organisation working with farmer groups in the areas of high out-migration and another engaged in developing urban agriculture. The facilitator ensures participants consider the various levels of cause and pay attention to cross-cutting issues, especially how woman and men are differently affected. The facilitator intervenes as little as possible, typically with brief questions, such as: How might the high levels of malnutrition that have been reported in the region be affecting people’s

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infection risks? What effects might out-migration be having on HIV risks of those moving to or already living in the towns and cities? What effects might there be on those remaining in the areas they come from? How may agriculture and NRM in these areas be contributing to those HIV risks? Are there any government policies that are contributing to out-migration or inadvertently making it more risky?

Once susceptibility has been adequately discussed, the group might then turn to resistance. Participants are encouraged to consider the actions at different levels that are helping people to avoid infection risks, actions whose effect is uncertain and actions supporting resistance that could be developed. A participant from the AIDS NGO might bring out the importance of migrants understanding AIDS and other health risks before they start out. Their work has contributed to increasing awareness but some young women, and men, unable to find a job, still become involved in sex work. A participant from the urban agriculture NGO might point to the income opportunities that some recent migrants have developed in intensive production and marketing. He admits that, to this point, few women migrants have been involved in these ventures. The NGO working on agriculture in the areas of high out-migration might describe some of the local initiatives that are showing real potential for reinforcing rural livelihoods. The NGO hasn’t to this point considered how their work might have a bearing on resistance or resilience but a number of ideas emerge in the discussion.

Vulnerability to AIDS and resilience to its consequences are considered in similar fashion. Organisers may find that vulnerability followed by susceptibility is a more natural sequence and improves the flow of ideas, since the two sections involving responses are then together. How the exercise is shaped and where one would hope to arrive at its conclusion depends on whether it is used in an inception, capacity building or other workshop. For the inception workshop, possible objectives might be a clearer, shared sense of the role that innovation in agriculture/NRM plays in resistance and resilience; also ideas on where local innovations might be sought and opportunities for collaboration between the health/AIDS and agriculture/NRM-oriented organisations.

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